Section 1 - Personal

Who is going to make the application (policyowner)?

Applicant

Title * Select Mr Master Mrs Miss Dr Prof. Baroness Lord Viscount Dame Ms Lady Last name *

First name * Middle name(s)

Type in your home address * Post code *

Daytime telephone * Email *

Section 2 - Whose life is to be insured?

Single or joint life? * Select Single life Joint life 1st death Joint life 2nd death

Ist life assured

Title * Select Mr Master Mrs Miss Dr Prof. Baroness Lord Viscount Dame Ms Lady Last name *

First name Middle name(s)

DOB * Occupation * Income (£)

Do you smoke? Select Yes No

We need to know your income because life offcies impose restrictions on how much life cover you can have in relation to your income.

2nd life assured (joint lives)

Title Select Mr Master Mrs Miss Dr Prof. Baroness Lord Viscount Dame Ms Lady Last name

First name Middle name(s)

DOB Occupation Income (£)

Do you smoke? Select Yes No

We need to know your income because life offcies impose restrictions on how much life cover you can have in relation to your income.

Section 3 - Existing protection

Do you have any existing life assurance? Select Yes No

Section 4 - Protection needs

Mortgage

Do you want to protect your mortgage? Select Yes No

If Yes, what type? Select Repayment Interest Only Repayment and Interest Only amount outstanding (£)

Loan repayment date Do you have any existing life assurance? Select Yes No

If Yes, how much? (£) Remaining policy term - years

Other loans

f Yes, the amount outstanding (£) Loan repayment date

Income

Would you want to suppliment income? Select Yes No

If Yes, how much p.a?(£) (maximum 10 x income)

How long would you like the income to be paid?

Would you like any income to increase? Select Yes No If Yes by how much? Select 1% pa 2% pa 3% pa 4% pa 5% pa RPI

Do you have any existing life assurance to cover income? Select Yes No

If Yes, how much? (£) Remaining policy term years

To insure your life on death? Select Yes No and or to insure on diagnosis of a critical illness? Select Yes No

Please provide any comment...

I have read the Terms and Conditions *

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